侵及胰腺晚期胃癌的外科治疗

回顾性分析我院1995年1月1日~2000年1月1日施行的晚期胃癌侵犯胰腺手术46例患者的临床资料。结果46例患者中,根治性切除26例,姑息性手术20例。其中胃次全切除加胰体尾部和脾切除11例,全胃切除加胰体尾部和脾切除9例,胃次全切除加胰十二指肠切除3例,全胃切除加胰十二指肠切除2例,胃次全切除加胰体尾部切除1例;姑息性胃大部分切除术11例,短路手术(胃空肠吻合)7例,探查活检加空肠造瘘术1例,单纯探查活检术1例。随访40例,术后1、3和5年生存率,根治手术组分别为65·2%(15/23)、30·4%(7/23)和13%(3/23),姑息手术组分别为35·3%(6/17)、11·8%(2/17)和0。根治手术组术后1、3和5年生存率明显高于姑息手术组,χ2=4·62,P=0·030。初步研究结果提示,对晚期胃癌侵犯胰腺的患者,严格掌握手术适应证,选择合理的手术方式,注重患者围手术期的营养支持,这是降低并发症,提高联合胃胰切除手术成功率及远期生存率的重要因素。     

Surgical treatment of gastric cancer invading the oesophagus

INTRODUCTION: There is controversy regarding which type of surgical treatment is most appropriate for upper gastric cancer invading the oesophagus. METHODS: A review of the pertinent literature was carried out regarding oesophageal involvement in gastric cancer. RESULTS: Invasion of the oesophagus occurred in 26-63% of Western surgical series. It was more frequent in Borrmann IV type, linitis plastica, pT3-pT4, diffuse type by Lauren, N+ or tumours exceeding 5 cm in diameter. Lymphatic tumour spread was caudad (coeliac nodes, hepatoduodenal nodes, paraortic nodes) but mediastinal nodes were also involved if tumour growth in the oesophagus exceeded 3 cm or if there was transmural oesophageal infiltration. In Western countries there was less than 30% 5-year survival and no long-term survivors when hepatoduodenal or mediastinal nodes were metastatic. Mediastinal dissection through thoracotomy did not provide any benefit. CONCLUSIONS: A rational approach involves total gastrectomy plus partial oesophagectomy. Abdominal transhiatal resection may be performed in the case of a localized, non-infiltrating tumour and oesophageal involvement <2 cm. However, infiltrating, poorly differentiated or Borrmann III-IV tumours require a right thoracotomy to achieve a longer margin of clearance. When oesophageal involvement is >3 cm, or hepatoduodenal or mediastinal nodes are positive, no surgical procedure is curative and the literature demonstrates that extended aggressive surgery has no benefits.     

Controversies in surgical treatment of gastric cancer

Conservative surgery is performed for patients with early gastric cancer, according to the guideline proposed from Japanese Gastric Cancer Society. There are many kinds of operations, such as ordinary open surgery, laparoscopic-assisted gastrectomy, laparoscopic intragastric surgery, pyrolus preserving gastrectomy, hand-assisted laparoscopic surgery. Indications of the operations are various, but it is necessary to have standard indication for each procedure. Standard operation for advanced gastric cancer in Japan is D2 gastrectomy. Surgeons in Eastern world believed that D1 + alpha or D1 + adjuvant radio-chemotherapy are the standard treatments, because of high incidence of mortality and morbidity after D2 dissection. In Japan, D4 dissection has been performed for patients with nodal involvement, and the validity of D4 dissection is now studied by two randomized trials. Combined resection for T4 tumor is believed to be mandatory. However, the validity of pancreato-splenectomy to yield a complete clearance of No. 10 or No. 11 lymph node station is in controversial, because of high incidence of the postoperative development of pancreatic fistula, anastomotic insufficiency and abscess. There was no prospective study to confirm the effect of omentectomy. Patients with advanced gastric cancer showing a serosal invasion-diameter less than 2.5 cm have less risk of peritoneal recurrence. It may be valuable to perform randomized controlled study consisting of omentum-preserving gastrectomy and gastrectomy with omentectomy. Prognosis of patients with peritoneal dissemination was improved by intraperitoneal chomo hyporthormia and peritonectomy, and prospective studies should be done to compare the effects of systemic chemotherapy and regional chemotherapy combined with peritonectomy. Furthermore, effects of neoadjuvant chemotherapy with cytoreduction with R0 resection should be confirmed by prospective studies.     

Principles of surgical radicality in the treatment of gastric cancer

The aim of curative surgery is to perform an RO resection, that is, the volume of resection should encompass the tumor volume in toto and fall in healthy margins. This means maintaining a transection margin 6 cm from the tumor and removing neighboring organs altogether if involved by the tumor. With regard to lymphadenectomy, the adequate number to be retrieved which allows a proper staging, and probably the optimal results, is about 25 lymph nodes.     

Prognosis of T4 gastric carcinoma patients: an appraisal of aggressive surgical treatment

BACKGROUND AND OBJECTIVES: Despite precipitous drop in the incidence of gastric carcinoma in Japan, it is still one of the leading causes of death associated with malignant disease. Once the contiguous organs are involved the prognosis becomes dismal. Prognostic factors governing the survival of patients with T4 gastric carcinoma remain unclear. METHODS: Between 1980 and 1998, 150 patients were treated for T4 gastric carcinoma. Results and prognostic factors were evaluated by univariate and multivariate analyses. RESULTS: With a 73% resectability, patients with tumor resection had a significantly (P < 0.0001) improved survival rate. Within an acceptable operative mortality (2.6%), apparently curative cases had survival benefit (P < 0.0001) over noncurative cases. In the multivariate analysis, the death risk increased by 2.18 (relative risk) when splenectomy was spared from the operative procedure (P < 0.0071). Presence of esophageal invasion was the other independent prognostic factor in T4 gastric carcinoma patients (relative risk 2.11). Conventional prognostic factors along with the type of organs invaded by the carcinoma had no impact on prognosis. CONCLUSIONS: Patients with T4 gastric carcinoma might be benefited from aggressive surgery with a curative intent. Whenever possible, splenectomy should be done along with invaded organ resection.     

The treatment of gastric cancer with combined surgical resection and chemotherapy

A series of 156 patients with gastric cancer during a 15-year period were reviewed retrospectively to determine the effectiveness of combined surgery and adjuvant chemotherapy. The patients were divided into a 9-year prechemotherapy period and a 6-year chemotherapy period. Review of the data revealed an increase in the incidence of distant disease. The utilization of surgery as the only mode of treatment declined. Combination surgery and adjuvant chemotherapy utilization increased. Comparison of survival for surgery vs. adjuvant chemotherapy, expressed as percentage of survivors for each year, revealed an increase at 1 and 2 years with no difference at 3 years for all stages. A similar comparison for patients with regional spread showed an increase at 1,2, and 3 years with no difference thereafter. The 5-year survival was 5% for both groups. The data has suggested that surgery and adjuvant chemotherapy increases 1-, 2-, and 3-year survival rates but does not affect the longterm results.     

早期胃癌的诊断和外科手术进展

胃癌曾是继肺癌之后第二常见的恶性肿瘤,但近年来其发病率在世界范围内呈普遍下降趋势.目前已排在肺癌、乳腺癌、和结直肠癌之后,成为第四位常见肿瘤,其中42%的病例发生在中国[1].据WHO统计,至2005年,胃癌仍是中国癌症发病和死亡的首位肿瘤.如何降低胃癌的发病率、提高胃癌的早期诊断率已成为临床面临的刻不容缓的问题.     

Prognosis of breast cancer with axillary node metastases after surgical treatment only

Out of 753 patients with breast cancer treated with radical mastectomy from 1968 to 1970 at the National Cancer Institute of Milan, Italy, 308 had histologically proven positive nodes. The number of positive nodes was not dependent on the location of the primary tumour, its diameter and the patient's age.Extracapsular invasion was related to the number of positive nodes at a statistically significant level: P value 2 × 10⁻⁹. Survival was influenced by the number of positive nodes and extension of metastases beyond their capsule and age. Each of these criteria had an independent impact on survival.Three subgroups with different prognosis were identified in patients older than 40: (a) with a single involved node and 69.9% 10 year survival rate, (b) patients with two or more nodes with matastatic deposit still confined within node capsule and 47.4% 10 year survival rate, (c) patients with two or more involved nodes and extracapsular invasion and 25.3% 10 year survival rate.In patients younger than 40 no subgroup was identified: this group had an intermediate 10 year survival rate (50.9%).The authors conclude that there is a need (a) of re-consideration of the prognosis of patients with positive nodes and (b) to agree on the definition of “high-risk patients”.     

Results of specialization in the surgical treatment of gastric cancer in Peru

Background The best results in the surgical treatment of gastric cancer are those obtained by the Japanese surgical school that emphasizes D2 lymphadenectomy as a fundamental principle for obtaining better local control of the disease. However, this technique has not gained wide acceptance in the West, owing to the fact that the results of Japanese studies have not been reproduced frequently in Western countries. In recent years, a series of studies have recommended the centralization of gastric cancer treatment in specialized surgical units in order to obtain results similar to those achieved by Japanese centers. The objective of this study was to describe the specialization process and to show the short-term results obtained in the surgical treatment of gastric cancer in the Specialized Unit of the Rebagliati National Hospital, the largest general referral hospital in Lima, Peru. Methods In the year 2000 a specialized service was created for the surgical treatment of gastric cancer, initiating a process that included the establishment of surgical treatment guidelines, training in the Japanese surgical technique, and progress along the learning curve for D2 lymphadenectomy. Clinical, surgical, and pathological data were recorded prospectively in a fixed format, considering that strict documentation of cases was also an important step within this process. Results Between January 1, 2004, and December 31, 2005, 243 consecutive patients with a proven diagnosis of gastric adenocarcinoma were admitted to the operating theater for surgical treatment. During this study period, morbidity was 22.7% and hospital mortality, 2.8%. The numbers (mean ± SD) of resected lymph nodes for distal gastrectomy and total gastrectomy were 37.3 ± 12.4 and 45.3 ± 14.5, respectively. Hospital stay was 13 days for distal gastrectomy as well as for total gastrectomy. Conclusion According to our results, adequate training in the Japanese surgical technique, progress along the learning curve for D2 lymphadenectomy, and the establishment of specialized units are highly recommended for the surgical treatment of gastric cancer in Western referral hospitals. Calle Guatemala 165 — Dpto. 101, Urb. Santa Patricia, La Molina, Lima, Perú     

Prognosis of patients with advanced gastric cancer by HER2 status and trastuzumab treatment

Background

The purpose of this study was to evaluate the impact of human epidermal growth factor receptor 2 (HER2) status and trastuzumab treatment on the prognosis of patients with advanced gastric cancer (AGC).

Methods

We retrospectively analyzed 364 AGC patients who received systemic chemotherapy. To evaluate the impact of trastuzumab exposure during any type of chemotherapy, our analysis used time-varying covariates to avoid a possible lead-time bias.

Results

Among the 364 patients, 58 (15.9 %) were HER2-positive. The median overall survival of the HER2-positive patients treated with trastuzumab (n = 43) was significantly longer than that of the HER2-negative patients [n = 306; 24.7 vs. 13.9 months, with an adjusted hazard ratio (HR) of 0.58; 95 % confidence interval (CI), 0.36–0.95; P = 0.03]. Notably, 22 patients continued with trastuzumab beyond the date of progression. By contrast, the HER2-positive patients not treated with trastuzumab (n = 15) showed survival similar to that of the HER2-negative patients (13.5 vs. 13.9 months, with an adjusted HR of 1.04; 95 % CI, 0.52–2.11; P = 0.91). According to the multivariate analysis, exposure to trastuzumab was independently associated with a better prognosis (HR 0.56; 95 % CI; 0.33–0.93; P = 0.026).

Conclusions

Recent HER2-positive AGC patients have a better prognosis than HER2-negative patients, particularly when treated with trastuzumab.     

残胃癌的淋巴结转移规律与外科治疗特点

回顾近年文献,综述残胃癌淋巴结转移规律及其合理的根治术式,认为残胃癌的淋巴结清除范围应为①B-Ⅰ式重建残胃癌切除范围为第1、2、3、4sa、4sb、7、8a、9、10、11组淋巴结,必要时清除第12、14、13、8p淋巴结;②B-Ⅱ式重建残胃癌切除范围为胃肠吻合口附近口侧及肛侧空肠各10cm,同时清除空肠系膜淋巴结;③食管受累有望根治性切除病例应开胸并清除第19、20、111、110及108组淋巴结。残胃癌施行治愈性切除可获得较高生存率。     

Time trends of surgical treatment and the prognosis for Japanese patients with gastric cancer

The incidence of gastric cancer is much higher in Japan than in other countries even though diagnostics and treatments of such patients have improved. The objective of this study was to present an overview of the past, present and future of surgical treatment for our patients with gastric cancer. We analysed data on 2152 Japanese men and women with gastric cancer who underwent surgical resection from 1965 to 1995 at Kyushu University in Fukuoka, Japan, based on a univariate and the multivariate analysis. We focused on time trends of surgical treatment and the postoperative outcome. Over the years, there have been favourable changes in the numbers of patients with early gastric cancer. In all cases of gastric cancer, the rate of 18% in the first six year period (group 1) was 57% in the last 5 year period (group 6). Size of the tumour was smaller, well-differentiated tumour tissue was more common, and lymphatic involvement was less frequent. Lymph node metastasis, liver metastasis and peritoneal dissemination all decreased. Extensive lymph node dissection was more frequently done and the rate of curative resection (curability A and B) increased. With increases in identifying the early stage of cancer and better perioperative care, mortality rates 30 days after the surgery greatly decreased. Multivariate analysis revealed that the 10 factors of depth of invasion, lymph node metastasis, lymph node dissection, tumour size, liver metastasis, peritoneal dissemination, lymphatic invasion, vascular invasion, lesion in the whole stomach and lesion in the middle stomach were independent factors for determining the prognosis. Detection of the tumour in an early stage, standardized surgical treatment, including routine lymph node dissection, close follow-up schedules and better perioperative management are expected to increase survival time for patients with this malignancy.